Healthcare Provider Details

I. General information

NPI: 1629022678
Provider Name (Legal Business Name): MARIA YNES BRUECKNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 EAST NIZHONI BLVD.
GALLUP NM
87301
US

IV. Provider business mailing address

P.O. BOX 1337
GALLUP NM
87305-1337
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-726-8557
Mailing address:
  • Phone: 505-722-1000
  • Fax: 505-726-8557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number32304
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: